Aislinn Antrim, Associate Editor

Fewer than half of inmates in jails and prisons surveyed for a new study said that they would accept a COVID-19 vaccine, whereas the majority either said they wanted to wait before getting a vaccine or would refuse one, according to a press release.

The study, conducted by the CDC and researchers at the University of Washington (UW), was published on the CDC’s Morbidity and Mortality Weekly Report. The investigators surveyed more than 5000 inmates, both men and women, in late 2020 from 3 prisons and 13 jails in Washington, California, Florida, and Texas.

“This is a population already at risk for COVID-19, and outbreaks among incarcerated people can worsen inequities in COVID-19 outcomes as well as contribute to spread in the surrounding community,” said lead author Marc Stern, MD, MPH, affiliate assistant professor of health services in the UW School of Public Health, in the press release. “So culturally and health-literacy informed interventions are needed to help them feel more confident about getting vaccinated.”

Only 45% said they were willing to receive the COVID-19 vaccine, more than 45% said they would refuse, and nearly 10% said they might or were not sure whether they would receive it.

The most common reasons the participants cited for vaccine hesitancy fell into the categories of waiting for more information or to see others take it first, and efficacy or safety concerns. The most common reason given for refusal was distrust of the health care system, correctional or government personnel, and institutions.

The survey was conducted before vaccines were available, when researchers found that Black and younger respondents were the least willing to get the vaccine. In the press release, the investigators noted that these findings are not surprising given historical mistreatment and distrust of medical and governmental institutions.

“People of color are subject to a ‘double whammy’—they are at higher risk of serious illness from COVID-19, and they are disproportionately incarcerated, living in facilities where they are more likely to become infected,” Stern said in the press release. “I hope this study sheds light on the need to find ways of assuring high levels of vaccination of incarcerated individuals, not just for their own health, but for the health of the community.”

CDC, UW study finds significant vaccine distrust within incarcerated populations, increasing risks [news release]. University of Washington; April 1, 2021. 

https://www.washington.edu/news/2021/04/01/cdc-uw-study-finds-significant-vaccine-distrust-within-incarcerated-populations-increasing-risks/

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The most common reason given for refusal of a COVID-19 vaccine was distrust of the health care system, correctional or government personnel, and institutions.

Study Finds Significant Vaccine Distrust Among Incarcerated Populations

With many recent developments in the treatment landscape for breast cancer, a session at the Community Oncology Alliance virtual 2021 conferenceon Thursday reviewed some exciting new data and approvals for triple-negative breast cancer (TNBC) and human epidermal growth factor receptor 2 (HER2)-positive breast cancer.

Presenter Joyce A. O’Shaughnessy, MD, began her discussion with a review of several recent clinical trials in patients with TNBC. First, she said the IMpassion130 trial examined nabpaclitaxel in combination with atezolizumab and found improvements in overall survival (OS). However, she noted that the IMpassion131 trial—which investigated paclitaxel either with or without atezolizumab—showed no improvement in OS when atezolizumab was added.

“We really are a bit flummoxed,” O’Shaughnessy said, adding that there must have been unseen prognostic variables that made the control group overperform so substantially.

Turning her attention to the recent approval of pembrolizumab in combination with chemotherapy for patients with TNBC, O’Shaughnessy said researchers found that 38% of patients had a combined positive score of 10% or more, although they have not yet seen survival data from this study.

Preoperative trials have been ongoing in this patient population, with experts hoping to have approvals for checkpoint inhibitors in addition to preoperative chemotherapy, O’Shaughnessy said. The KEYNOTE-522 study, which is investigating checkpoint inhibitors in preoperative patients, found a 13.6% improvement in pathologic complete response (pCR) in breasts and lymph nodes.

Similarly, O’Shaughnessy said the KEYNOTE-355 study is finding promising data on event-free survival, although the median follow-up for that study is still just 15.5 months. O’Shaughnessy said she is hoping for another interim analysis later in 2021, which could potentially lead to an approval in the preoperative and neoadjuvant setting.

Finally, O’Shaughnessy reviewed the approval of 

, a TROP-2 targeted antibody drug conjugate that was approved on April 7. She said clinical trials of this drug showed huge improvements in OS from 6 to 12 months compared to a single-agent chemotherapy.

“This is a marvelous result, and this has been very well utilized now in later tNBC,” O’Shaughnessy said.

Next, O’Shaughnessy reviewed recent developments in the treatment of HER2-positive breast cancer. Tucatinib very selectively inhibits HER2, she said, allowing it to get great brain penetration. The randomized HER2CLIMB trial saw not only improvements in progression-free survival (PFS), but also a surprising improvement in OS with a statistically significant hazard ratio of 0.6, O’Shaughnessy said.

Notably, in patients with brain metastases, O’Shaughnessy said the HER2CLIMB trial saw a 55% reduction in risk of progression or death in the total patient population, potentially allowing clinicians to put off the use of radiation therapy in these patients.

Next, O’Shaughnessy discussed recent research on trastuzumab deruxtecan in heavily pre-treated patients with HER2-positive breast cancer and a median of 6 lines of prior therapy. Investigators found a median PFS of 19 months and a median OS of 24 months, which O’Shaughnessy said is significant.

Finally, the use of neratinib as post-neoadjuvant therapy for patients less than 1 year after treatment with trastuzumab is also showing promise. Investigators have found a 7.4% absolute improvement in invasive disease-free survival at 60 months and a 9.1% improvement in overall survival at 8 years, according to her presentation.

“I think this is a really important option for [estrogen receptor-positive] patients, along with endocrine therapy, to give them every change of remaining progression-free,” O’Shaughnessy concluded.

O’Shaughnessy J. Managing New Drugs in Breast Cancer: Therapeutic Opportunities and Challenges; April 8, 2021. Presented at: Community Oncology Alliance Virtual 2021 Conference; Accessed April 8, 2021.

A session at the Community Oncology Alliance virtual 2021 conference noted that clinical trials have found promising new treatments for patients with breast cancer, offering opportunities for future new approvals and indications. 

New Drugs Show Promise in Triple-Negative, HER2-Positive Breast Cancer

Although patients and health care professionals frequently and incorrectly equate palliative care with end-of-life care, 2 important studies have reinforced that earlier integration of palliative care in cancer treatment can improve patients’ quality of life and could potentially extend survival.

In a session Thursday at the Community Oncology Alliance virtual 2021 conference, presenter Morvarid Razaie, DO, HMDC, FACOI, said palliative care is an approach that improves quality of life for patients and their families who are facing a life-threatening and potentially life-limiting illness. The approach focuses on alleviating suffering and managing symptoms, including physical symptoms, mental health, and difficult decisions that can come with cancer diagnoses.

“Palliative care unfortunately gets incorporated late in patients’ care whenever it comes to late-stage cancer,” Razaie said. “We really need to try to incorporate it earlier on.”

Guidelines for palliative care include patients’ understanding and education around their illness, symptom management, decision-making about their treatments, and coping with their diagnosis. These interventions can also involve family members and caretakers, Razaie said, noting that the ENABLE II study encouraged participants to choose a family member to take part in the interventions.

Razaie reviewed 2 studies of palliative care and its impact on patients with cancer, both of which found promising results. The first, a study with findings published in the 

), investigated early integration of palliative care in patients with advanced stage non-small cell lung cancer (NSCLC).

Investigators studied earlier palliative care integrated with standard oncologic treatments compared to standard oncologic care alone. Patients in the palliative care group had at least monthly contact with a palliative care provider until their death, although Razaie noted that patients in the control group could receive palliative care services if they requested them.

The study enrolled 151 patients and found no significant difference between the groups at baseline for quality of life and mood. According to the study findings, patients who received earlier palliative care had higher scores on the Functional Assessment of Cancer Therapy – Lung (FACT-L) scale, the FACT-Lung Cancer Subscale, (FACT-LCS), and Trial Outcome Index (TOI). Researchers also noted a lower percentage of patients with depression, improved quality of life, and, significantly, longer survival.

Razaie noted that the percentage of patients with a first-time antidepressant prescription was similar between both the intervention group and the control group, and the median duration of follow-up for patients who died was 5.7 months. Furthermore, more patients in the standard-of-care group received aggressive end-of-life care, such as chemotherapy or resuscitation efforts. Fewer patients in the control group had addressed their resuscitation preferences, which Razaie said is essential for patients with life-threatening diagnoses.

Next, Razaie discussed the ENABLE II study, which compared palliative care interventions to usual care for patients newly diagnosed with cancer. Unlike the 

 study, the ENABLE II study did not limit participants to those with NSCLC. The primary endpoints were quality of life, symptom intensity, and mood.

According to Razaie’s presentation, the intervention arm included case management, encouraged patient participation and empowerment, a distress thermometer to measure patients’ distress levels, and monthly shared medical appointments. The usual care arm received normal standards of care and were allowed to use all oncologic and support services without restrictions.

Interestingly, Razaie said this study found similar results in quality-of-life scores but no statistically significant medical differences. For example, there were no significant differences in the number of days spent in the hospital or intensive care unit, and no difference in the number of emergency department visits. There was also no statistically significant difference in survival and a limited impact on symptom intensity. However, the investigators noted higher quality of life scores, lower depression scores, and lower depressed moods.

When considering how to implement palliative care into an oncology practice, Razaie said it is important to consider the wide-ranging needs of patients. With a dedicated team to address the complex physical, emotional, psychosocial, and spiritual needs of this patient population, Razaie said incorporating a palliative care practice can actually relieve time for oncology teams, allowing them to focus more on the necessary treatments.

Accessibility and access to palliative care is also a challenge, Razaie said, although availability has grown approximately 150% over the past decade. Expansion first requires a robust referral base however, so she said spreading awareness among physicians should be a priority, both through building partnerships and including palliative care in medical school curriculums and trainings.

Rezaie M. Integrating Palliative Care Into Community Practice; April 8, 2021. Presented at: Community Oncology Alliance virtual 2021 conference. Accessed April 8, 2021.

In patients who received early palliative care, researchers noted a lower percentage of patients with depression, improved quality of life, and, significantly, longer survival. 

Integrating Palliative Care Early in Cancer Diagnosis Improves Quality of Life, May Improve Outcomes

Although they said there is only anecdotal evidence so far, a group of panelists at the Community Oncology Alliance (COA) virtual 2021 conference anticipate more late-stage cancer diagnoses as a result of delayed screenings and physician visits during the COVID-19 pandemic.

The panelists, moderated by Barry Russo, MBA, chief executive officer of the Center for Cancer & Blood Disorders & OneOncology, said the impacts of the pandemic on their day-to-day operations, staff management, and patient interactions were challenging, although they all said they were proud of their various organizations and how their staff handled the rapid changes in spring 2020.

Some of the most immediate changes involved physical changes to their offices and spaces where patients would normally be, according to speaker Lucio Gordan, MD, managing physician and president of the Florida Cancer Specialists & Research Institute. Gordan said his institute created a large COVID-19 team with nurses, physicians, pharmacists, and others, who helped disseminate necessary information and make decisions. They also leapt into action to separate chemotherapy chairs and create dividers to go between them, to ensure patient safety.

“I think all of us were able to maintain a focus on patient care and delivering the best care at all times,” Gordan said.

James Perry, MD, chief medical officer of Alliance Cancer Specialists, said staff management became a challenge as many employees had COVID-19 scares or diagnoses forcing them to stay home. Staff members often covered for each other when needed, and Perry said one of the major challenges was getting testing performed in a timely matter, especially over the summer. However, he said employees were largely ready and willing to jump in wherever needed.

Panelist Jennifer Pichoske, MS, AOCNP, FNP, chief clinical officer of the Hematology-Oncology Associates of Central New York, echoed Perry’s sentiments that staff members banded together to help each other. She added that their facility implemented an A and B formation, in which one group managed patients in the office while the others worked from home on case management and triaging patient calls. This system allowed them to safely assume that if a few employees in the office had to quarantine at home, others who had been working at home would be able to come into the office.

When discussing patient impacts of the pandemic, the panelists agreed that one of the major ongoing consequences will be more late-stage diagnoses and stage migration. Gordan said that he has only seen anecdotal situations so far but added that it is only a matter of time before clinicians begin seeing an uptick.

Perry agreed, adding, “We clearly saw less screening, and there’s consequences to that.”

He added that some patients who presented with later-stage cancers had noted their symptoms earlier, but attributed them to COVID-19, although these cases are also anecdotal. Perry emphasized that more data and information will be necessary to determine the true impacts of the pandemic on cancer diagnoses.

Pichoske said several physicians at her facility have commented on seeing larger tumors and later stage diagnoses, especially among their large population of patients with breast cancer. She also said they have seen a few oncologic emergencies, and although Pichoske said it is not an overwhelming issue yet, she expects these problems will continue.

Despite these concerning trends, all of the panelists said that their facilities have begun the process of reopening, although they are at different stages. Perry said his facility has now resumed relatively normal activities and Pichoske said they now have all staff members back in the office, although both added that they will continue using telemedicine as needed.

Gordan said they have paused their reopening progress until May, given a current spike in cases in Florida. Still, he expressed optimism about the ability of oncology care providers to handle ongoing challenges presented by the pandemic.

“I trust in the resilience of community oncology…that we’ll be able to get these patients in as quickly as possible to try to mitigate the migration and worse outcomes,” Gordan concluded.

Russo B, Gordan L, Perry J, Pichoske J. Learnings from COVID-19; April 8, 2021. Presented at: Community Oncology Association virtual 2021 conference. Accessed April 8, 2021.

Panelists at the Community Oncology Alliance (COA) virtual 2021 conference said the impacts of the pandemic on their day-to-day operations were challenging, although they all said they were proud of how their staff handled the rapid changes in spring of 2020. 